Tuesday, December 30, 2014

Are ARBs safe in patients experiencing angioedema on an ACE inhibitor?

This was the topic of a recent review in CCJM.

ARBs are known to be associated with angioedema but the risk is quite low. The mechanism is unknown and there is no plausible mechanism in common with ACEIs. It cannot be established conclusively from empirical evidence that there is any true cross sensitivity. However, given the speculation that patients with ACEI induced angioedema may have an “allergic diathesis” predisposing them to angioedema from unrelated mechanisms the authors of the review advise caution, as do various other experts and guidelines. These cautions include patient education as to possible risk and shared decision making. For appropriate indications the benefits of ARBs are substantial in patients ACEI intolerant and must be weighed against the very small risk.

How are medical students taught EBM?

Here's a systematic review. Some sections of particular interest:

Sixty-seven percent of interventions indicated that they trained learners to search PubMed 15, 18–21, 23–25. In three interventions 14, 16, 17, MEDLINE, a subset of PubMed, was mentioned as a distinct information resource for which students received training. In one instance, MEDLINE was accessed via Ovid 17, whereas in the two other interventions, it is unclear if MEDLINE was introduced via the PubMed interface or via a subscription service, such as Ovid or EBSCO.

In addition to PubMed, a spectrum of information resource types was introduced, including UpToDate (25%), AccessMedicine (17%), DynaMed (17%), Google (17%), Cochrane EBM Reviews (8%), DxPlain (8%), National Guideline Clearinghouse (8%), and ACP Journal Club (8%).

The findings represent a shift form the original pure teaching of user appraised primary searching (e.g. PubMed) to pre-processed (filtered) resources. As I have pointed out before this is an evolving and controversial area.

From the discussion section:

EBM advocates encourage physicians to provide their patients with best evidence as a component of the EBM process and shared decision making 46. However, best evidence that is valuable to a physician, such as a meta-analyses featured in PubMed, may or may not be of value to a patient due to its complex nature. Therefore, it is notable that only a single training presented a consumer health information resource. This is a valuable missed opportunity for librarians, who have a long history of promoting consumer information 47, to introduce medical students to these important tools, which can facilitate the shared decision-making process and empower the patient. In the future, librarians should consider introducing consumer health resources into EBM training.

This raises another controversy: is it the physician's job to translate the evidence into plain language for the patient or should the patient access consumer oriented filtered resources as a part of shared decision making? Either way the authors understand the importance of patient preferences and values as key components of EBM.

Today's policy makers who advocate for top-down and population-based medicine deny this aspect and are thus opposed to EBM whether they admit it or not.

Monday, December 29, 2014

Diet trials and cardiovascular disease

Here is a free full text review in the green journal.

Key points:

Diets that focus only on reduction of dietary cholesterol and saturated fats have been disappointing.

The addition of certain beneficial dietary constituents (e.g. the Mediterranean diet) has been shown to be more beneficial.

(This does not negate the cholesterol hypothesis. If dietary fat restriction is accompanied by increased carbohydrate intake the metabolic syndrome might be precipitated in susceptible patients. Non-statin LDL reduction has been shown to reduce coronary disease).

The Mediterranean and similar diets may produce benefits that rival those of statins.

CT coronary angiography to evaluate chest pain

Here is a recent review.

From the review:

For patients with acute or stable chest pain syndromes, CCTA is a safe and effective diagnostic modality. The strength of CCTA is its high NPV to rule out CAD, which carries independent prognostic value for short- and long-term coronary events, better than any individual or combination of risk factors or any other diagnostic test.

Early CCTA is a viable alternative to stress testing in the triage of patients with an acute chest pain syndrome. By using CCTA, the length of hospital stay is reduced dramatically, allowing for a faster yet safe discharge from the ED or chest pain unit…

For patients with stable chest pain, the clinical benefit of CCTA is less established.

Sunday, December 28, 2014

Diet and exercise: anti inflammtory effect in DM 2

From a recent study:

Methods and Results Systemic markers of inflammation were determined in a 12‐month, real‐world, multicenter, randomized, controlled trial that investigated the effect of diet, diet plus physical activity, and usual care in 593 individuals with newly diagnosed T2D. During the first 6 months, serum C‐reactive protein (CRP) improved by −21 (−36 to −1.4)% and −22 (−38 to −3.1)% in diet and diet plus physical activity arms versus usual care. There were also improvements in adiponectin and soluble intercellular adhesion molecule‐1 (sICAM‐1). Though medication‐adjusted CRP was improved between 6 and 12 months for usual care, both interventions were more successful in reducing the relative risk of a high‐risk CRP level of greater then 3 mg/L (risk ratios of 0.72 [0.55 to 0.95] for diet versus usual care and 0.67 [0.50 to 0.90] for diet plus activity versus usual care). Furthermore, sICAM‐1 (a marker of vascular risk), remained substantially lower than usual care in both intervention arms at 12 months.

Conclusions Motivational, unsupervised diet and/or diet plus physical activity interventions given soon after diagnosis in real‐world healthcare settings improve markers of inflammation and cardiovascular risk in patients with T2D, even after accounting for the effect of adjustments to medication to try and control blood pressure, glycated hemoglobin, and lipids.

How do physicians search for answers to clinical questions arising in the ICU?

From a single center study:

In a 20-bed surgical intensive care unit in a large, tertiary-care teaching hospital, informationists shadowed clinicians for 2 48-hour periods to record questions, noting when they were asked and whether they were answered. Thirty-eight percent of 112 recorded questions remained unanswered.

That's a lot of unanswered questions and may reflect a lack of time, lack of searching skills or the fact that for many questions there is no external evidence available.

As to the resources used, the findings reflect a great deal of variation:

Participants were satisfied two-thirds of the time when they looked up an answer from a resource (23 of 37 observed instances). PubMed (n=10 or 26%), Google (n=10 or 26%), UpToDate (n=7 or 18%), Wikipedia (n=4 or 10%), and other evidence-based sources (n=2 or 5%) were the most frequently queried online sources. They also accessed known journal articles, practice guidelines, handbooks, pocket guides, and handwritten notes (n=6 or 15%) to answer questions.

This is all over the map and clearly not the rigorous approach advocated by traditional EBM teaching. And at Hopkins no less.

Saturday, December 27, 2014

Invasive fungal infections following natural disasters

Clusters of unusual fungal infections in the aftermath of natural disasters are increasingly being reported. Here is a free full text review describing some of the outbreaks and speculating on the reasons. Of regional interest to me was the cluster of invasive mucormycosis soft tissue infections following the Joplin MO tornado in 2011.

The choosing wisely list in palliative care

Here is a portion of the list from the web page:

Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
In advanced dementia, studies have found feeding tubes do not result in improved survival, prevention of aspiration pneumonia, or improved healing of pressure ulcers. Feeding tube use in such patients has actually been associated with pressure ulcer development, use of physical and pharmacological restraints, and patient distress about the tube itself. Assistance with oral feeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems; in the final phase of this disease, assisted feeding may focus on comfort and human interaction more than nutritional goals.

Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
Numerous studies—including randomized trials—provide evidence that palliative care improves pain and symptom control, improves family satisfaction with care and reduces costs. Palliative care does not accelerate death, and may prolong life in selected populations.

The important thing to remember here is that palliative care is not always end of life care.

Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.
In about a quarter of patients with ICDs, the defibrillator fires within weeks preceding death. For patients with advanced irreversible diseases, defibrillator shocks rarely prevent death, may be painful to patients and are distressing to caregivers/family members. Currently there are no formal practice protocols to address deactivation; fewer than 10% of hospices have official policies. Advance care planning discussions should include the option of deactivating the ICD when it no longer supports the patient’s goals.

Friday, December 26, 2014

Brugada syndrome: the latest

Here's a new review.

From the article:

Originally, three repolarization patterns were described: a) Type-1 ECG pattern, in which a coved ST-segment elevation greater than or equal to 2 mm is followed by a negative T-wave, with little or no isoelectric separation, with this feature being present in greater then 1 right precordial lead (from V1 to V3); b) Type-2 ECG pattern, also characterized by a ST-segment elevation but followed by a positive or biphasic T-wave that results in a saddle-back configuration; c) Type-3 ECG pattern, a right precordial ST-segment elevation less than or equal to 1 mm either with a coved-type or a saddle-back morphology..so far, only the ECG type 1 pattern is the sine qua non BrS diagnosis: J-point elevation of greater than 2 mm with a coved (downward convex) ST segment (Figure 1).9 Both type 2 and 3 are not considered diagnostic. The ECG type 1 pattern may be spontaneously evident or induced by a provocative drug challenge test using intravenous Class 1A or 1C antiarrhythmic drugs.

Concerning the genetics:

Brugada syndrome is a disease with an autosomal dominant pattern of transmission. Incomplete penetrance is frequent in families, and the disease can be sporadic in up to 60% of patients.17 In 1998, the first pathogenic mutation in the SCN5A gene was identified.18 This gene encodes the alpha subunit of the cardiac sodium channel (Nav1.5). Since then, more than 350 pathogenic mutations in several genes have been published (SCN5A, GPD1L, SCN1B, SCN2B, SCN3B, RANGRF, SLMAP, KCNE3, KCNJ8, HCN4, KCNE5, KCND3, CACNA1C, CACNB2B, CACNA2D1, and TRPM4) (Table 1).19 These genes encode subunits of cardiac sodium, potassium, and calcium channels as well as genes involved in the trafficking or regulation of these channels. Despite the high number of gene mutations, only about 35% of BrS patients have been determined to have a genetic cause. Of them, nearly 30% carry a pathogenic mutation in the SCN5A gene.20 All other genes together are responsible for about 5% of all BrS cases. Therefore, 65% of cases do not have a genetic origin.

Wednesday, December 24, 2014


From a recent review:

Canagliflozin, a novel agent that lowers plasma glucose by decreasing glucose reabsorption at the proximal tubules of nephrons, inhibits the sodium–glucose cotransporter 2. Data suggest a decrease in hemoglobin A1C by about 1% in both fasting and postprandial plasma glucose levels, when canagliflozin was studied as monotherapy or with various combinations of metformin, pioglitazone, sulfonylurea, and insulin. Interestingly, canagliflozin use in geriatric patients and in those with renal impairment showed decreased efficacy and an increased risk of adverse reactions. These include, but are not limited to, hypotension, renal impairment, hyperkalemia, hypoglycemia, genital mycotic infections, hypersensitivity reactions, and increases in low-density lipoproteins. Hypoglycemia is a rare occurrence when canagliflozin is used alone but can occur more frequently when used in combination with sulfonylurea or insulin. This article reviews the pharmacology of canagliflozin, examines available clinical trials for efficacy and safety, and describes its role in diabetes management.

Tuesday, December 23, 2014

What clinicians need to know about Ebola

Here's a nice update from Mayo Clinic Proceedings. It is available as free full text. Concerning the shift in infection control recommendations the authors note:

Before transmission of EVD to health care workers in Dallas, the CDC’s position was that patients with EVD could be cared for safely in any hospital in the United States.2 The fact that 2 health care workers taking reasonable precautions acquired EVD in a US hospital has resulted in a paradigm shift. There is a new realization that although all health care facilities should be prepared to recognize and perform initial stabilization of a patient with EVD, subsequent care of the patient is extremely resource intensive and is best performed at a specialized center. The other lesson that we have learned from the Dallas experience is that although PPE is an important component of patient care, just having PPE available is not enough.

Indications for ECMO in ARDS

Experience gained in the 2009 flu pandemic has refined our approach to the use of ECMO. Recommendations form a consensus conference have recently been published. Here is a summary of the indications, form the document:

2.1 Use of VV ECMO should be considered if the PaO2/FiO2 ratio is below 50 mmHg when FiO2 = 1 for at least three hours, despite a protective ventilation strategy (involving use of prone positioning) (CR).

2.2 Use of VV ECMO should be discussed if the PaO2/FiO2 ratio is below 80 mmHg when FiO2 = 1 for more than six hours, despite a protective ventilation strategy (involving use of prone positioning) (CR).

2.3 Use of VV ECMO should be discussed if, associated with a protective ventilation strategy (involving use of prone positioning), there is respiratory acidosis with a pH less than 7.20 for over six hours (CR).

2.4 There is no indication for VA ECMO in ARDS when respiratory failure is isolated. VA ECMO can be considered if there is concurrent cardiogenic shock (CR).

2.5 When acute cor pulmonale prompts use of ECMO, it is not a mandatory indication for VA ECMO (CR).

Concerning extra-corporeal CO2 removal (ECCO2R), the authors said it could not be recommended at this time pending further study.

Antibiotic de-escalation

In a population of ICU patients with severe sepsis or septic shock it was associated with improved survival in this study:

A total of 712 patients with severe sepsis or septic shock at ICU admission were treated empirically with broad-spectrum antibiotics. Of these, 628 were evaluated (84 died before cultures were available). De-escalation was applied in 219 patients (34.9 %). By multivariate analysis, factors independently associated with in-hospital mortality were septic shock, SOFA score the day of culture results, and inadequate empirical antimicrobial therapy, whereas de-escalation therapy was a protective factor [Odds-Ratio (OR) 0.58; 95 % confidence interval (CI) 0.36–0.93). Analysis of the 403 patients with adequate empirical therapy revealed that the factor associated with mortality was SOFA score on the day of culture results, whereas de-escalation therapy was a protective factor (OR 0.54; 95 % CI 0.33–0.89). The PS-adjusted logistic regression models confirmed that de-escalation therapy was a protective factor in both analyses. De-escalation therapy was also a protective factor for 90-day mortality.

Monday, December 22, 2014

More data on dabigatran versus warfarin

From a register-based observational study:

Among patients with a history of stroke/transient ischemic attack and prior VKA experience, switching to dabigatran was associated with an increased stroke/transient ischemic attack rate for both dabigatran doses compared with continuing on warfarin (D110 hazard ratio [HR] 1.99; 95% confidence interval [CI], 1.42-2.78; D150 HR 2.34; 95% CI, 1.60-3.41). Among prior stroke/transient ischemic attack patients who were new starters on dabigatran or warfarin, the rate of stroke/transient ischemic attack for both doses of dabigatran was similar to or lower than warfarin (D110 HR 0.64; 95% CI, 0.50-0.80; D150 HR 0.92l; 95% CI, 0.73-1.15).

In this register-based study, VKA-experienced patients with a history of stroke or transient ischemic attack who switched to dabigatran therapy had an increased rate of stroke compared with patients persisting with warfarin therapy.

Practical aspects of antibiotic lock therapy

Here's a guide from Stanford's antibiotic stewardship site.

Adopting the EMR: trading one set of problems for another

A recent review on the impact of the electronic medical record reminds of a sobering fact: that despite years of wishful thinking, research findings have been disappointing. It would be generous to say they have been mixed because by and large the positive findings have been confined to soft and non validated surrogate metrics. As suggested in the title of this post the EMR seems to create as many problems as it addresses. From the review:

Electronic provider order entry processes may lower the chance for errors based on the legibility or misplacement of paper orders.2 Other types of errors, for example, automatic renewals, cancellations of orders, and inappropriate dosing of medications, may actually increase with the EHR.3 Cut-and-paste options also increase the risk for errors in documentation.4 Computer systems are vulnerable to malfunctioning hardware and software and may run slowly. In addition, access could be difficult in a busy healthcare setting.5...

The primary care physician evaluating the multitude and diverse problems of medically complex older adult patients is especially vulnerable to the inefficiencies of EHR utilization. Check-box features and the automatic importation of laboratory values and medication profiles can lead to “note bloat” and boilerplate documentation that can obscure important clinical findings from the reader.6,7

The boilerplate “note bloat” referenced above is the EMR's answer to the doctor's handwriting, trading one form of illegibility for another.

The EMR is but one of several “systems” (e.g. the hospitalist model, rapid response teams, performance measures) which, though touted as solutions to various health care problems, have one by one been disappointing when subjected to scientific scrutiny.

Rate versus rhythm control for atrial fibrillation

Ever since the AFFIRM study showed generally comparable outcomes for rate and rhythm control strategies in atrial fibrillation a number of additional studies have been done. These were the topic of a recent systematic review and meta-analysis. From the review:

Data Synthesis: 200 articles (162 studies) involving 28 836 patients were included. When pharmacologic rate- and rhythm-control strategies were compared, strength of evidence (SOE) was moderate supporting comparable efficacy with regard to all-cause mortality (odds ratio [OR], 1.34 [95% CI, 0.89 to 2.02]), cardiac mortality (OR, 0.96 [CI, 0.77 to 1.20]), and stroke (OR, 0.99 [CI, 0.76 to 1.30]) in older patients with mild AF symptoms. Few studies compared rate-control therapies and included outcomes of interest, which limited conclusions. For the effect of rhythm-control therapies in reducing AF recurrence, SOE was high favoring pulmonary vein isolation versus antiarrhythmic medications (OR, 5.87 [CI, 3.18 to 10.85]) and the surgical maze procedure (including pulmonary vein isolation) done during other cardiac surgery versus other cardiac surgery alone (OR, 7.94 [CI, 3.63 to 17.36]).

Limitation: Studies were heterogeneous in interventions, populations, settings, and outcomes.

Conclusion: Pharmacologic rate- and rhythm-control strategies have comparable efficacy across outcomes in primarily older patients with mild AF symptoms. Pulmonary vein isolation is better than antiarrhythmic medications at reducing recurrences of AF in younger patients with paroxysmal AF and mild structural heart disease. Future research should address uncertainties related to subgroups of interest and the effect of different therapies on long-term clinical outcomes.

Sunday, December 21, 2014

Blastomycsis presenting as necrotizing pneumonia

Here is an abstract presentation at SHM 2014 describing such a case, serving as a reminder that:

Blasto is a great mimicker and can present as a variety of forms of pneumonia.

It is not a strict opportunist and can cause disease in immunocompetent patients.

It can present as ARDS.

In today's time constrained, performance driven world over diagnosis of bacterial pneumonia is increasingly recognized. As a hospitalist you are likely to be handed “pneumonia patients” who do not have pneumonia at all, but rather have non-infectious parenchymal lung disease or an unusual infection. It is worthwhile to take a diagnostic time out when you encounter such patients.

Safety of endoscopy soon after acute MI

Here is a report of a series of patients form the University of Missouri:

Eighty-seven patients underwent EGD within 30 days of having an MI. No major complications were observed. Minor complications occurred in 27 of 87 patients (31.0%), including mild hypotension, mild bradycardia, or increased chest pain...

Conclusions: EGD appears relatively safe for the diagnosis and management of upper gastrointestinal bleeding in patients with acute MI.

The mean time post MI to endoscopy was 5.2 days.

Trends in hospitalization for atrial fibrillation

From 2000 to 2010:

Methods and Results—With the use of the Nationwide Inpatient Sample from 2000 through 2010, we identified AF-related hospitalizations using International Classification of Diseases, 9th Revision, Clinical Modification code 427.31 as the principal discharge diagnosis. Overall AF hospitalizations increased by 23% from 2000 to 2010, particularly in patients greater than or equal to 65 years of age. The most frequent coexisting conditions were hypertension (60.0%), diabetes mellitus (21.5%), and chronic pulmonary disease (20.0%). Overall in-hospital mortality was 1%. The mortality rate was highest in the group of patients greater than or equal to 80 years of age (1.9%) and in the group of patients with concomitant heart failure (8.2%). In-hospital mortality rate decreased significantly from 1.2% in 2000 to 0.9% in 2010 (29.2% decrease; P less than 0.001). Although there was no significant change in mean length of stay, mean cost of AF hospitalization increased significantly from $6410 in 2001 to $8439 in 2010 (24.0% increase; P less than 0.001).

Conclusions—Hospitalization rates for AF have increased exponentially among US adults from 2000 to 2010. The proportion of comorbid chronic diseases has also increased significantly. The last decade has witnessed an overall decline in hospital mortality; however, the hospitalization cost has significantly increased.

Saturday, December 20, 2014

Update on severe sepsis and septic shock

This recently published paper from Mayo Clinic Proceedings updates septic shock management in light of the new findings from ProCESS but avoids all the post ProCESS and post ARISE hype that has been swirling around. It is concise and available as free full text.

Via Hospital Medicine Virtual Journal Club.

The CDC Yellow Book

A travel health resource.

Toxicologic desperation: euglycemic hyperinsulinemia and lipid rescue for calcium blocker overdose

From a case report and mini-review:

Calcium channel blockers (CCBs) drugs are widely used in the treatment of cardiovascular diseases. CCB poisoning is associated with significant cardiovascular toxicity and is potentially fatal. Currently, there is no specific antidote and the treatment of CCB poisoning is supportive; however, this supportive therapy is often insufficient.

Although this is only a single case report I thought it useful to post here because it contains a brief review of the literature and a discussion of the purported mechanisms of severe calcium blocker poisoning and the mechanisms of treatment.

Hypoglycemia in hospitalized patients: more than just a nuisance

From a recent survey:

An anonymised questionnaire was e-mailed to lead organisers at the 142 acute NHS Trusts that contributed to the National Diabetes Inpatient Audit 2012…

..12 serious adverse events were reported from nine trusts: three deaths; two cases of permanent cerebral damage; two successfully resuscitated cardiac arrests; three seizures; and two undefined events. Insulin therapy was implicated in 10 events. Importantly, three events with two deaths occurred in patients who had received insulin/dextrose to correct hyperkalaemia; only one of whom had diabetes.

An alarming number of serious adverse events was reported: 12 serious adverse events with three deaths over a 1-year period in 41 Trusts. This may be the tip of the iceberg, considering the potential under-reporting.

Addison disease

A review in American Family Physician.

Friday, December 19, 2014

New atrial fibrillation guidelines

From AHA/ACC/HRS. Free full text here.

Ileal pouch infection with C diff

From a recent article in the American Journal of Gastroenterology:

Clostridium difficile (C. difficile) infection (CDI) following total proctocolectomy and ileal pouch-anal anastomosis has been increasingly recognized over the past 5 years. CDI of the ileal pouch has been recognized in ~10% of symptomatic patients seen at a tertiary referral center for pouch dysfunction. In contrast to colonic CDI in the general population or in patients with inflammatory bowel disease, postoperative antibiotic exposure and the use of immunosuppressive agents or proton pump inhibitors do not appear to be associated with CDI of the pouch. Male gender, recent hospitalization, and presurgery antibiotic use were shown to be risk factors for ileal pouch CDI...Postcolectomy CDI likely represents a spectrum of disease processes, varying from asymptomatic colonization to severe symptomatic infection. CDI should be considered in any patient with an ileal pouch presenting with a change in “normal” symptom pattern or treatment-refractory disease.

Non convulsive seizure related altered mental status

When patients present with altered mental status of unclear etiology consider this from a recent study:

To identify the prevalence of NCS and other EEG abnormalities in ED patients with AMS…

Two hundred fifty-nine patients were enrolled (median age: 60, 54% female). Overall, 202/259 of EEGs were interpreted as abnormal (78%, 95% confidence interval [CI], 73-83%). The most common abnormality was background slowing (58%, 95% CI, 52-68%) indicating underlying encephalopathy. NCS (including non-convulsive status epilepticus [NCSE]) was detected in 5% (95% CI, 3-8%) of patients. The regression analysis predicting EEG abnormality showed a highly significant effect of age (P less than .001, adjusted odds ratio 1.66 [95% CI, 1.36-2.02] per 10-year age increment). IRA for EEG interpretations was modest (κ: 0.45, 95% CI, 0.36-0.54).

The prevalence of EEG abnormalities in ED patients with undifferentiated AMS is significant. ED physicians should consider EEG in the evaluation of patients with AMS and a high suspicion of NCS/NCSE.

Rethinking IV hydralazine

IV hydralazine is popular in hospitals because it is old, familiar and easy to use. A recent post at Emergency Medicine PharmD serves as a reminder of the potential for adverse effects. Among the downsides are unpredictable pharmacokinetics (it can hang around much longer than expected in some patients) and pharmacodynamics (unexpected and poorly tolerated hypotension can occur), activation of the sympathetic nervous system and cerebral autoregulatory failure due to its vasodilating effects.

As stated in the post, hydralazine is contraindicated in many true hypertensive emergencies and is not the drug of choice for any of them. And if it's not a hypertensive emergency (severe asymptomatic hypertension with no target organ damage) one should question whether a parenteral antihypertensive of any kind is warranted.

Thursday, December 18, 2014

Point of care blood glucose testing may soon disappear from the ICU if certain regulators have their way

No, I'm not kidding. Check this out from a recent article in Mayo Clinic Proceedings. From the article:

The CMS regulates all laboratory testing (except research) on humans in the United States through regulations established by the Clinical and Laboratory Improvement Amendments (CLIA) of 1988...
No POC BGM has ever been cleared by the FDA for critically ill patients.11 Therefore, these devices are being used “off-label” in the ICU, operating room, recovery room, and emergency department...

In contrast to the off label use of drugs, the off label use of laboratory methods is against the regulations. More from the article:

The CMS recently became aware that POC BGMs are being used in hospitals off-label and is ready to enforce the prohibition of their off-label use, according to 2 recent letters from the New York State Department of Health.

Despite the fact that virtually all hospitals have been doing this for decades and it has become a standard of care, CMS has only recently become aware of it!! Well that illustrates how profoundly out of touch they are with what really goes on at the “point of care.”

According to one of the authors in the accompanying video CMS is poised to cite or even shut down hospitals. The authors propose a moratorium on further regulatory action.

How do medical school faculty get information on line?

This recent paper from the Journal of the Medical Library Association describes how faculty members utilize information resources. A major limitation is that it is a single center study and may reflect trends that are peculiar to the culture of the institution. It is available as free full text and there is a lot to unpack. An area of particular interest to me was that of faculty members' preferences for patient care look up:

..the 180 respondents to the question rarely searched the 13 point-of-care databases listed in the survey for clinical or patient-care information. Over 90% stated that they never used 5 of the databases for clinical or patient care, and another 5 databases had between 75% and 90% of respondents never using them. For example, UpToDate was used daily by 4.8% of respondents but was never used by 64.1% of respondents for clinical or patient care purposes. MD Consult was the most used by all respondents, with 43.6% reporting using it at least a few times a year or more for clinical or patient care information.

There's a lot of scatter here but a few patterns are suggested. Filtered resources such as DynaMed and UpToDate, wildly popular among residents and private physicians, were hardly used at all by faculty, who tended to prefer repositories of books and journals such as MD Consult and Access Medicine. The filtered resources are more geared for focused clinical questions whereas the repositories are better suited for background reading and that may be more suitable for the teaching objectives of faculty.

Evidence based medicine (EBM) has evolved concerning information retrieval. Original teaching held that a Medline search and critical appraisal (a phrase coined for this use by the founders of EBM) should be done by the user at the point of care. That teaching has given way to a shift toward the use of filtered resources (secondary sources) which deliver information that has been searched and critically appraised by others. Proponents of filtered resources argue that primary searching and critical appraisal is too time consuming for clinicians. Purists decry this practice as capitulation to laziness. I discussed this trend in greater detail in a recent post on the history of EBM:

Dr. Brian Haynes was asked whether EBM was too much work for the busy clinician. When one considers the steps involved in searching, critical appraisal and application it does seem a daunting task. Certainly it would have been too time consuming before the era of computer searching. On line searching was available in the 1980s (you had to go to considerable trouble to set it up) but had not yet reached prime time even by the time EBM was announced to the world in 1992.

Haynes said that he and his colleagues were working from the beginning to make the process user friendly in everyday practice. They have been exploring ways to put best evidence into secondary sources, including even textbooks (some EBM purists decry the use of textbooks) so that doctors will not have to do primary literature searches and critical appraisal. Currently available secondary resources, said Haynes, may not be where they need to be yet but are improving.

As Guyatt pointed out the leaders realized early on that getting all clinicians to search and critically appraise the literature individually was an unattainable ideal. The best that could be done was to educate clinicians in the principles of EBM so they could then make more intelligent and effective use of secondary sources. Evidence derived from such sources has already been critically appraised and has been referred to as “pre-processed” evidence. Some EBM purists, taking a negative view of this approach, consider it an unfortunate compromise and have called it “evidence based capitulation.”

Overdoses with new generation anticonvulsants

From a recently published observational study:

There were 116 gabapentin, 67 lamotrigine, 15 levetiracetam, 15 tiagabine, 56 topiramate, 23 pregabalin, and 55 oxcarbazepine cases. Overdose of newer anticonvulsants frequently results in altered mental status. Seizures may be more common with tiagabine, lamotrigine, and oxcarbazepine. There was one death reported from intentional overdose of topiramate..the risk of a more severe outcome score was significantly increased with tiagabine relative to other drugs (β = 2.8, p = 0.001). Lamotrigine ranked highest in terms of toxicity (HT = 1.66) and number of interventions performed (HI = 1.17), and levetiracetam the lowest (HT = 0.98; HI = 0.88). We could not identify a dose-effect in these data which likely reflects the limitations of self-reported doses. Despite limitations of these data, the risk of more severe outcome scores appear to be higher with tiagabine overdose while lamotrigine overdose appears to result in more reported signs, symptoms, and interventions.

A clinical score to help exclude Legionella in community acquired pneumonia

From the American Journal of Medicine:

Currently used antigen tests and culture have limited sensitivity with important time delays, making empirical broad-spectrum coverage necessary. Therefore, a score with 6 variables recently has been proposed. We sought to validate these parameters in an independent cohort...
Of 1939 included patients, the infectious cause was known in 594 (28.9%), including Streptococcus pneumoniae in 264 (13.6%) and Legionella sp. in 37 (1.9%). The proposed clinical predictors fever, cough, hyponatremia, lactate dehydrogenase, C-reactive protein, and platelet count were all associated or tended to be associated with Legionella cause. A logistic regression analysis including all these predictors showed excellent discrimination with an AUC of 0.91 (95% confidence interval, 0.87-0.94). The original dichotomized score showed good discrimination (AUC, 0.73; 95% confidence interval, 0.65-0.81) and a high negative predictive value of 99% for patients with less than 2 parameters present.
With the use of a large independent patient sample from an international database, this analysis validates previously proposed clinical variables to accurately rule out Legionella sp., which may help to optimize initial empiric therapy.

Wednesday, December 17, 2014

Inappropriate cath lab activation due to pseudoSTEMI

Inappropriate treatment of patients presenting with chest pain is an increasingly recognized consequence of the performance driven STEMI versus non-STEMI designation. The most widely discussed examples of this take the form of missed coronary occlusion due to over reliance on simple ST segment criteria. Another aspect of the problem was illustrated in this recent paper: inappropriate cath lab activation due to STMI mimics. From the article:

There were a total of 139 activations with 77 having a STEMI diagnosis confirmed and 62 activations where there was no STEMI. The inappropriate activations resulted from a combination of atypical symptoms and misinterpretation of the ECG (45% due to anterior ST-segment elevation) on patient presentation.

The fact that almost half the cath lab activations were inappropriate is concerning enough. Worse, though, was the fact that this occurred at an academic medical center.

STEMI versus pericarditis: new criteria proposed

From a recent article in the American Journal of Medicine:

..This study aims to assess whether QRS and QT duration permit distinguishing acute pericarditis and acute transmural myocardial ischemia.

Clinical records and 12-lead electrocardiogram (ECG) at ×2 magnification were analyzed in 79 patients with acute pericarditis and in 71 with acute ST-segment elevation myocardial infarction (STEMI).

ECG leads with maximal ST-segment elevation showed longer QRS complex and shorter QT interval than leads with isoelectric ST segment in patients with STEMI (QRS: 85.9 ± 13.6 ms vs 81.3 ± 10.4 ms, P = .01; QT: 364.4 ± 38.6 vs 370.9 ± 37.0 ms, P = .04), but not in patients with pericarditis (QRS: 81.5 ± 12.5 ms vs 81.0 ± 7.9 ms, P = .69; QT: 347.9 ± 32.4 vs 347.3 ± 35.1 ms, P = .83). QT interval dispersion among the 12-ECG leads was greater in STEMI than in patients with pericarditis (69.8 ± 20.8 ms vs 50.6 ± 20.2 ms, P less than .001). The diagnostic yield of classical ECG criteria (PR deviation and J point level in lead aVR and the number of leads with ST-segment elevation, ST-segment depression, and PR-segment depression) increased significantly (P = .012) when the QRS and QT changes were added to the diagnostic algorithm.

Patients with acute STEMI, but not those with acute pericarditis, show prolongation of QRS complex and shortening of QT interval in ECG leads with ST-segment elevation.

Update on social media as medical education tools

This is a nice compilation of medical education social media resources. Coming from an emergency medicine journal it is biased toward that field but, after all, emergency medicine is where it's mostly happening right now.  

Monday, December 15, 2014

Non cardiac surgery after PCI

This is one of the most vexing perioperative issues for hospitalists and was the topic of a recent review article in the American Journal of Cardiology. Surgery post PCI is a difficult situation because it is the interface of two pro-thrombotic conditions, a local one (the recently manipulated artery which has not had time to endothelialize) and a systemic pro-thrombotic state resulting from the surgery.

The review offers a summary of current guidelines and more recent evidence along with a suggested approach. From the review, concerning the guidelines:

Current consensus multisociety guidelines suggest delaying elective surgery for greater than or equal to 1 year after DES implantation and for greater than or equal to 4 to 6 weeks after BMS implantation. If surgery is warranted before that period, it should be performed while on DAPT if safe. Minimums of 6 to 12 months and 4 to 6 weeks of DAPT, respectively, after DES and BMS implantation before NCS are recommended in national guidelines. If surgery is anticipated within 30 days of revascularization or if DAPT is not feasible, balloon angioplasty without stenting may be a reasonable strategy if NCS is anticipated. These recommendations are based largely on expert opinion in conjunction with limited and variable evidence based on first-generation DESs.

The authors note that newer generation drug eluging stents may be safer and thus allow earlier interruption of DAPT. In the suggested approach that follows, however, they emphasize that this remains unproven:

We propose the following simplified approach to such patients. (1) It is reasonable to postpone elective surgical procedures for greater than or equal to 6 weeks after BMS implantation and for greater than or equal to1 year after first-generation DES implantation. Second-generation DESs have a more favorable thrombogenicity profile, and emerging data suggest that it may be safe to discontinue DAPT as early as 3 months after stent implantation. Consequently, it may be feasible to safely perform NCS 3 to 6 months after second-generation DES implantation, but this remains unproved. (2) Urgent or unplanned surgery should be performed on DAPT if feasible, but this is the exception.

Sunday, December 14, 2014

What is subacute kidney injury?

From a recent paper:

Background and objectives The epidemiology of AKI and CKD has been described. However, the epidemiology of progressively worsening kidney function (subacute kidney injury [s-AKI]) developing over a longer time frame than defined for AKI (7 days), but shorter than defined for CKD (90 days), is completely unknown...
Conclusions Close to 1% of hospitalized patients develop s-AKI. This condition is independently associated with increased hospital mortality, and the risk for death increases with s-AKI severity. Patients with s-AKI had a better outcome and were less likely to require renal replacement therapy than patients with AKI.

Via Hospital Medicine Virtual Journal Club.

Saturday, December 13, 2014

Prevention of recurrent kidney stones

New guidelines are out from the ACP available as free full text here.

From the guideline document:

Recommendation 1: ACP recommends management with increased fluid intake spread throughout the day to achieve at least 2 L of urine per day to prevent recurrent nephrolithiasis. (Grade: weak recommendation, low-quality evidence)
Recommendation 2: ACP recommends pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol to prevent recurrent nephrolithiasis in patients with active disease in which increased fluid intake fails to reduce the formation of stones. (Grade: weak recommendation, moderate-quality evidence)

The evidence for dietary interventions was mixed and not strong enough for the authors to include a recommendation. Also, the guideline states that the evidence was insufficient to support pre-treatment or on-treatment stone analysis or determination of urine composition.

Friday, December 12, 2014

Glycemic control and stroke outcomes

Hyperglycemia is associated with worse stroke outcomes and it is widely assumed that intensive insulin treatment of hyperglycemic patients hospitalized with acute stroke will improve this. But the evidence does not support that assumption, at least according to this systematic review, when the target blood sugar was 72 to 135 mg/dL.

Wednesday, December 10, 2014

Tuesday, December 09, 2014

Intermittent bolus versus continuous infusion PPI for high risk bleeding ulcers

This systematic review and meta-analysis found no difference and concluded:

Intermittent PPI therapy is comparable to the current guideline-recommended regimen of intravenous bolus plus a continuous infusion of PPIs in patients with endoscopically treated high-risk bleeding ulcers. Guidelines should be revised to recommend intermittent PPI therapy.

Monday, December 08, 2014

Management of febrile neutropenia: Do hospitalists add value?

This study, which showed improved care processes and decreased mortality during a gradual increase in hospitalist care of these patients, will probably be cited by the boosters of hospital medicine as another example of added value. However, as the authors themselves pointed out, the improved outcomes are more likely the result of secular trends.

The full text of the paper is worth reading because it describes what I'll call the second wave of increased utilization of hospitalists, that is, hospitalists increasingly acting as the primary attending for subspecialty patients. In the large health care system reported in the referenced paper subspecialists had almost entirely turned their admissions over to hospitalists by the end of the study period.

Across all the subspecialties do hospitalists do a better job? Research to date does not indicate that they do, but more studies are needed.

EMR frustrations

This post from FIRM is another reminder to me that doctors are getting more outspoken in their negativity about the EMR. I don't know if that's because they're just now realizing it isn't living up to its promise or if doctors have become emboldened. Just a few years ago it was politically incorrect to question the value of the EMR.

Sunday, December 07, 2014

Is dexmedetomidine (Precedex) helpful during non invasive ventilation in patients with respiratory failure?

Not really, in this small study. It is an appealing idea and further research is needed.

Critical care choosing wisely list

The critical care list was a collaborative effort by 4 professional societies. The list is linked here at Intensive Care Medicine-Working Knowledge. It's a great list with the exception of item 1 which makes no sense to me:

1. Do not order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions;

My specific clinical question every morning is “how are the patient's chemistries today?” but that's not what the writers had in mind. If you're going to wait for a “clinical” (non-laboratory) question to trigger ordering labs what would that be? Do you wait for the patient to get confused or start having arrhythmias before ordering chemistries?

Hospital medicine had a similar recommendation but it said to stop ordering daily labs on stable patients. I can't argue with that wording but by the time patients are stabilized they're ready for discharge.

Saturday, December 06, 2014

Dr. Wes interviewed at AHA 2014 on the problems with MOC

Watch the video here.

Macrolides in the prevention of COPD exacerbations

This is getting increasing attention. From a recent review:

Chronic obstructive pulmonary disease (COPD) is one of the major health problems in the world. Long-term treatment with macrolide antibiotics is a recent development that has been reported to have beneficial effects on exacerbation frequency. These effects are not only attributed to the antimicrobial effect but also to the immune modulatory effect. Six randomized trials and 1 retrospective study have been performed to investigate the efficacy of macrolides in the prevention of acute exacerbations of COPD. Besides the beneficial effects on the occurrence of exacerbations of COPD, this treatment also seems to improve quality of life and is well tolerated. Antimicrobial resistance is one of the future issues to consider before implementing this therapy.

Persistent use of evidence based cardiac medications following hospital discharge

From registry data:

 We linked Medicare pharmacy claims data with 3,184 patients with non–ST-segment elevation MI greater than 65 years of age who were treated in 2006 at 253 hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology and American Heart Association guidelines registry. Using multivariate regression, we compared persistent filling of β blockers, angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, clopidogrel, and statins at 90 days and 1 year postdischarge between patients discharged from academic and nonacademic hospitals...Composite persistence to all EBMs prescribed at discharge was low and not significantly different between academic and nonacademic hospitals at 90 days (46% vs 45%, adjusted incidence rate ratio = 0.99, 95% confidence interval 0.95 to 1.04) and at 1 year (39% vs 39%, adjusted incidence rate ratio = 1.02, 95% confidence interval 0.98 to 1.07). 

This helps to further explain why core measure performance incentives do not work. Previous studies showed that performance driven evidence based medications prescribed at discharge are seldom titrated to goal in the clinic. This study takes it further and suggests that often they are not even continued at all.

Friday, December 05, 2014

Co-trimoxazole and sudden death

Co-trimoxazole was recently reported in the BMJ to be associated with an increased risk of sudden death in patients taking angiotensin converting enzyme inhibitors or angiotensin receptor blockers. The results were captured form administrative data bases in Canada. Hyperkalemia is the suspected mechanism. The drug is known to cause hyperkalemia due to potassium sparing diuretic properties of the trimethoprim component, which could act in synergy with ACEs and ARBs to produce severe hyperkalemia.

Via Dr. John M.

Posterior reversible encephalopathy syndrome (PRES)

Here is a free full text review.

From the review:

Characteristic clinical manifestations include non-localized headache unresponsive to analgesics, altered mental status, visual disturbances and seizures [1, 2]. RPLS is frequently associated with acute hypertension, preeclampsia or eclampsia, sepsis, renal failure, thrombotic thrombocytopenic purpura, hypercalcemia, hypomagnesium, autoimmune diseases, cytotoxic therapies and immunosuppressants [2].

When it comes to Bayesian statistics are we dumb as rocks?

Apparently the bloggers at Emergency Medicine Literature of Note think so based on this paper. Three quarters of survey respondents over a wide range of training and experience got the answer to this problem wrong:

“If a test to detect a disease whose prevalence is 1/1000 has a false positive rate of 5%, what is the chance that a person found to have a positive result actually has the disease, assuming you know nothing about the person's symptoms or signs?”

This assumes that the test had a sensitivity of 100%.

One of the bloggers surveyed his residents and got a similar rate of wrong answers.

The answer, as revealed in the paper, is 1.96%. The authors accepted any “ballpark” answer (2% or less) as correct for survey reporting purposes. I got the right answer but cheated a little by consulting this resource.

So what's the real problem here? I think it's a little over the top to say we're dumb as rocks about Bayesian statics, but the blog author is correct, in my opinion, in his assertion that, as a profession, our overall foundation in EBM is poor. (I would digress for a second to add that it goes way beyond our inability to do the math; or misunderstanding of EBM is pervasive on many levels).

I think most of us understand Bayesian principals qualitatively. We know, for example, not to rely on the D dimer assay as a rule out for VTE in a high risk population. That's Bayesian thinking. But the math is not something we do everyday. The challenge question set a trap for the survey respondents by applying a test with good inherent characteristics (low false positive rate) to a low disease prevalence population. Unless you really stop and think you're tempted to jump to an inappropriately high probability of disease.

Thursday, December 04, 2014

Prophylactic antibiotics in COPD

From a recent JAMA report (Clinical Evidence Synopsis):

Clinical Question Is prophylactic antibiotic treatment associated with fewer exacerbations or improved health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD)?
Bottom Line Continuous macrolide antibiotic use for prophylaxis was associated with a clinically significant reduction in COPD exacerbations. Pulsed antibiotic use was not associated with benefit. Continuous and pulsed antibiotics were associated with improved HRQOL, but this was not clinically significant.

Roflumilast is also available to prevent COPD exacerbations in selected patients.

Clostridium difficile treatment update

Although this free full text review focuses on fidaxomicin it's the best overview of all available treatments I've seen in a long time.

Fidaxomicin seems to be the winner hands down over vancomycin and metronidazole for initial treatment. It's even less costly than vancomycin unless you get the vancomycin compounded. Despite this UptoDate remains conservative about fidaxomicin saying though it can be considered, more studies are needed.

Are we making a dent in ARDS mortality?

Yes according to a presentation at Chest 2014 (via Medscape).

From the Medscape report:

For their retrospective analysis, the researchers identified 174,180 patients from the National Inpatient Sample database, which is the largest all-payer inpatient healthcare database in the United States, and documents about 8 million hospital stays annually...
From 1996 to 2011, there was a 14.6% absolute reduction in mortality — from 46.8% to 32.2% (relative reduction, 31.0%). From 2000 to 2005, the absolute reduction was 8.9%.

However it is difficult to know how many of these patients actually met criteria for ARDS, as data capture was done using an ECD 9 code database.

Of note, the slope of the downward mortality curve was steeper around the time of introduction of low tidal volume ventilation.

Wednesday, December 03, 2014

Takotsubo cardiomyopathy update

Here is one of many reviews on this subject.

Notable concerning this particular review:

It focuses only on apical ballooning, failing to mention the recent reports of stress associated transient basal and mid ventricular ballooning. Thus Takotsubo, a reference to the shape of a Japanese octopus trap, would not apply to all cases of the disorder leading to a recent shift to the term “stress cardiomyopathy.” The designation “inverted Takotsubo cardiomyopathy” has been used to describe some of these variants. That said, the most accepted diagnostic criteria, as cited in the review, focus on apical ballooning.

An emotional of physical stress can be cited in about two thirds of cases. Such a trigger, however, is not essential for the diagnosis.

Although acute structural neurologic processes and pheochromocytoma can cause a similar cardiomyopathy they are considered exclusions in the diagnostic criteria.

Although catecholamine toxicity is a favored mechanism, there may be others at play.

The authors state, concerning treatment:

Hemodynamically stable patients are often treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors and β-blockers. To reduce the risk of thromboembolism, patients with loss of motion of the LV apex should be treated with anticoagulant therapy until the contractility of the apex is improved unless there is a definite contraindication.
There is no consensus regarding long-term management of TCM, although it is reasonable to treat patients with β-blockers and ACE inhibitors during the ventricular recovery period. However, no data support the continuous use of these drugs for the prevention of TCM recurrence or improvement of survival rate. After LV function normalizes, physicians may consider discontinuation of these drugs.

Here is some background from my previous posts on this topic:

TCM in the general spectrum of brain-body medicine.

TCM can be a mimic of anterior STEMI.

TCM can be distinguished from STEMI by comparing the magnitude of troponin elevation with the degree of LV systolic dysfunction.

TCM may be precipitated by inhaled beta agonists.

Physical stress may be a more frequent trigger than emotional stress.

Mini-review from 2013.

Electrocardiographic differentiation from acute LAD occlusion.

TCM as one of the causes of troponin elevation in critical illness.

Mechanisms. This post emphasizes acute catecholamine toxicity and the associated pathologic change (contraction band necrosis). This post is a little dated and additional mechanisms have since been suggested, though the catecholamine view still holds considerable sway.

Paper in the Journal of the American Board of Family Medicine makes for hilarious blog fodder

I'll have to agree with the blogger at Rebel MD, that the premise of this study, that MOC is a valid indicator for medical knowledge is, to say the least, flawed. I don't think the results turned out the way they hoped, so I'll give them their due for publishing it in spite of that. From the paper:

Health disparities exist between rural and urban areas. Rural physicians may lack sufficient medical knowledge, which may lead to poor quality of care...

We studied 8361 FPs who took the American Board of Family Medicine maintenance of certification (MOC) examination in 2009. Data sources were examination results and data from a demographic survey of practice structure and activities, completed as part of the examination application process. FPs' location of practice was categorized as either rural or metropolitan using a moderate and conservative definition based on reported community size. Univariate statistics assessed differences in FP characteristics between rural and metropolitan areas. Logistic regression analyses determined the adjusted relationship between rural status and the odds of passing the MOC examination.

Metropolitan FPs were less likely than their rural counterparts to pass the MOC examination using both the moderate (odds ratio, 0.67; 95% confidence interval, 0.54-0.83) and conservative (odds ratio, 0.56; 95% confidence interval, 0.42-0.74) definitions. Physicians in solo practice were less likely to pass the examination than physicians in group practice.

Rural physicians were more likely to pass the MOC examination, suggesting that rural health disparities do not result from a lack of provider knowledge.

More evidence in favor of an age adjusted D dimer cutoff

I previously cited a positive study here.

Now there's a systematic review and meta-analysis that supports the practice.

Tuesday, December 02, 2014

Social media influence on journal readership

Findings from a new study in Circulation:

Methods and Results—Articles were randomized to receive targeted social media exposure from Circulation, including postings on the journal's Facebook and Twitter feeds. The primary end-point was 30-day article page views. We conducted an intention-to-treat analysis comparing article page views by the Wilcoxon Rank sum test between papers randomized to social media as compared to those in the control group, which received no social media from Circulation. Pre-specified subgroups included article type (population/clinical/basic), US vs. non-US corresponding author, and whether the manuscript received an editorial. Overall, 243 manuscripts were randomized: 121 in the social media arm and 122 in the control arm. There was no difference in median 30-day page views (409 [social media] vs 392 [control], p=0.80)...

Conclusion—A social media strategy for a cardiovascular journal did not increase the number of times an article was viewed. Further research is necessary to understand the ways in which social media can increase the impact of published cardiovascular research.

The major weakness in this study is that it looked only at the effect of Circulation's own social media outlets, not the effect of medical social media in general. The social media influence may be more than this study indicates although other studies suggest that it remains low despite the growing enthusiasm for FOAM and similar initiatives.

More from Cardiobrief and the Mayo Social Media Health Network.

Adding provider satisfaction as another goal to the triple aim

This article in the Annals of Family Medicine addresses the problem of health care provider burnout as an impediment to the triple aim of health care. The authors call for the addition of a fourth goal, the implementation of measures to improve provider satisfaction, thus moving from the triple aim to the quadruple aim.

The article is well referenced and cites multiple lines of evidence which tie physician burnout to bad patient outcomes.

There are multiple causes of provider burnout but most of the factors cited in the article relate in one way or another to the electronic medial record. In fact, the authors' first recommendation was to offload physicians by reducing CPOE and other clerical duties:

Implement team documentation: nurses, medical assistants, or other staff, present during the patient visit, entering some or all documentation into the EHR, assisting with order entry, prescription processing, and charge capture.

CPOE was originally hyped as a quality, safety and efficiency driver and it was politically incorrect to speak of it otherwise. Clinical outcomes data in the ensuing years were disappointing and physician skepticism grew as CPOE failed to live up to its promise.

Via DB's Medical Rants.


Free full text review.

Where is the hospitalist movement heading?

An article in ACP Hospitalist looks at the future of hospital medicine under the changing economic and regulatory environment. The article contains comments from Dr. Robert Wachter and other leaders in the movement about “value.” We all like the general notion of value but when hospitalist leaders talk about it they're talking about something artificial. It becomes artificial when it is reduced to something that can be measured. The data thus derived, they argue, must be presented to hospital administrators as proof of a program's value if that program is to succeed economically. But despite the fact that hospitalist leaders have been beating this drum for over a decade the main driver of hospitalist compensation continues to be the fact that there are just not enough hospitalists to go around. According to the article there's no sign that's about to change. Saturation with hospitalist care is by no means complete. There remain many primary care physicians who round on their own patients. Specialists are increasingly asking hospitalists to admit or comanage. Finally, according to the article, 30% of hospitals still do not have hospitalists.

Should the hospitalist job market someday become saturated we may indeed reach a point where compensation is derived by some artificially determined value metric. What might that consist of? As a possible answer the article discusses what the leaders believe to be the core skills of the future hospitalist. Of the many attributes mentioned none of them, unfortunately, fall in the realm of clinical excellence. This article paints a guarded prognosis for professional satisfaction as a hospitalist if your passion is clinical medicine. I still entertain the hope that the field will change direction but I see no signs of it happening.

Monday, December 01, 2014

Public reporting does not enhance quality; equally likely, it harms patients

It appears I'm not the only one who has been beating this drum.

Here's a post from FIRM.

This form Rebel MD.

Sunshine Act data are now public. Do patients care?

It hasn't been studied rigorously but there's this from Kane Scrutiny at Medscape:

It appears that—at least as far as patients are concerned—the hoopla over Open Payments was nearly as big a fizzle as was the supposed impending doom of Y2K. When I asked physicians what they heard from patients about their Sunshine Act payments, most responded, "I haven't heard a peep."

Salicylate poisoning

Here's a great pod cast and set of show notes from EM Basic. I posted on the topic earlier this year

Sunday, November 30, 2014

Platelet transfusion guidelines

Free full text published in the Annals of Internal Medicine.

VA physician and staff satisfaction with performance measures

From a recent JGIM study:

To describe primary care staff (clinicians and other staff) experiences with the use of performance metrics during the implementation of the Veterans Health Administration's (VHA) Patient Aligned Care Team (PACT) model of care...

Two hundred and forty-one of 337 (72 %) identified primary care clinic staff in PACT team and clinic administrative/other roles, from 15 VHA clinics in Oregon and Washington...

Primary care staff perceived that performance metrics: 1) led to delivery changes that were not always aligned with PACT principles, 2) did not accurately reflect patient-priorities, 3) represented an opportunity cost, 4) were imposed with little communication or transparency, and 5) were not well-adapted to team-based care.

Primary care staff perceived responding to performance metrics as time-consuming and not consistently aligned with PACT principles of care. The gaps between the theory and reality of performance metric implementation highlighted by PACT team members are important to consider as the medical home model is more widely implemented.

The VA is a stellar health system in the artificial world of metrics.

Non cardiac surgery after stroke and time course of increased risk

From a recently published Danish nationwide cohort study:

Main Outcomes and Measures Risk of major adverse cardiovascular events (MACE; including ischemic stroke, acute myocardial infarction, and cardiovascular mortality) and all-cause mortality up to 30 days after surgery. Odds ratios (ORs) were calculated by multivariable logistic regression models.
Results Crude incidence rates of MACE among patients with (n = 7137) and without (n = 474 046) prior stroke were 54.4 (95% CI, 49.1-59.9) vs 4.1 (95% CI, 3.9-4.2) per 1000 patients. Compared with patients without stroke, ORs for MACE were 14.23 (95% CI, 11.61-17.45) for stroke less than 3 months prior to surgery, 4.85 (95% CI, 3.32-7.08) for stroke 3 to less than 6 months prior, 3.04 (95% CI, 2.13-4.34) for stroke 6 to less than 12 months prior, and 2.47 (95% CI, 2.07-2.95) for stroke 12 months or more prior. MACE risks were at least as high for low-risk (OR, 9.96; 95% CI, 5.49-18.07 for stroke less than 3 months) and intermediate-risk (OR, 17.12; 95% CI, 13.68-21.42 for stroke less than 3 months) surgery compared with high-risk surgery (OR, 2.97; 95% CI, 0.98-9.01 for stroke less than 3 months) (P = .003 for interaction). Similar patterns were found for 30-day mortality: ORs were 3.07 (95% CI, 2.30-4.09) for stroke less than 3 months prior, 1.97 (95% CI, 1.22-3.19) for stroke 3 to less than 6 months prior, 1.45 (95% CI, 0.95-2.20) for stroke 6 to less than 12 months prior, and 1.46 (95% CI, 1.21-1.77) for stroke 12 months or more prior to surgery compared with patients without stroke. Cubic regression splines performed on the stroke subgroup supported that risk leveled off after 9 months.
Conclusions and Relevance A history of stroke was associated with adverse outcomes following surgery, in particular if time between stroke and surgery was less than 9 months. After 9 months, the associated risk appeared stable yet still increased compared with patients with no stroke. The time dependency of risk may warrant attention in future guidelines.

Saturday, November 29, 2014

Maintenance of certification (MOC): a focus group study of physicians' perceptions

Published in JAMA Internal Medicine:

At present, MOC is perceived by physicians as an inefficient and logistically difficult activity for learning or assessment, often irrelevant to practice, and of little benefit to physicians, patients, or society.

The Sunshine Act and the war on physicians

Great post on this topic over at Kevin MD.